Burnout and its associated factors among healthcare workers in COVID-19 isolation centres in Khartoum, Sudan: A cross-sectional study

Background Burnout prevalence and its consequences on healthcare workers during the Omicron wave are not well investigated in Sudan. This study aims to assess the prevalence of burnout and its associated factors among doctors and nurses during the omicron wave in COVID-19 isolation centres in Khartoum, Sudan. Method This cross-sectional survey study was conducted at multiple COVID-19 isolation centres in Khartoum state during the omicron wave of Coronavirus Disease 2019 between 20th February 2022 and 10th April 2022. A total of 306 doctors and nurses filled out the questionnaire, with a response rate of 64.8℅. They were recruited from 5 isolation centers scattered in the three cities of Khartoum Metropolis. The level of burnout was assessed using an online semi-structured questionnaire based on the Oldenburg Burnout Inventory questionnaire. Descriptive statistics were used for continuous variables and frequencies with percentages for categorical variables. The Chi-square test and Fisher exact test were used to identify variables associated with burnout. Logistic regression was used to determine the factors associated with burnout, and the p-value of ≤ .05 is considered statistically significant. Results The prevalence of burnout was 45.7%. Doctors were more likely to have burnout than nurses (OR: 2.01, CI 95% 1.24–3.27; p = 0.005). Also, married healthcare workers were more likely to suffer burnout than single healthcare workers (OR: 3.89, CI 95% 1.41–12.5; P = 0.013). The number of household members (p = 0.035) was associated with burnout among participants. Conclusion There is a high prevalence of burnout among healthcare workers in Khartoum Isolation Centers, which is more apparent among doctors.

sure it is accurate.  Data collection was anonymized, and the confidentiality of the study participants was maintained. If the data are held or will be held in a public repository, include URLs, Although public health measures, such as lockdowns, and social distancing, are crucial to reducing the spread of COVID-19, they increase stress, anxiety, and mental disorders. 10 The World Health Organization has recognized "burnout" as an "occupational phenomenon ."As lockdowns have significantly affected our work-life balance and work environments, much research has ascertained burnout and its contributing factors. 11 COVID-19 has a critical psychological impact on the community. 12 The length of the pandemic periodmore than two years -, the shortage of data about the virus treatment, and the unknown destiny of the pandemic resulted in many studies that showed a significant increase in cases of anxiety, psychological stress, and depressive disorders worldwide, and because the medical staff worked under severe psychological pressure: being highly stressed by losing patients and colleagues, preference of having long shifts to protect their families, having no clear curing strategies, and urgency in instructing interpretation, all incredibly highlight peaking of burnout among healthcare providers. [13][14][15][16] Burnout is a critical issue that generates inefficiency in healthcare organizations. 13 It lowers the quality of healthcare systems and negatively impacts patient prognosis. 17 Burnout affects the psychological wellbeing of the staff leading to medical errors. It makes the health system waste a lot of money and resourcesbecause some workers leave their jobs, compelling the system to recruit new staff and offer a new training program. It impedes the process of psychological support for patients, which is part of the treatment. 17,18 Healthcare providers who are emotionally exhausted -express burnout-cannot support patients psychologically nor make fateful medical decisions.

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While the pandemic affects the world, studies show that developed countries are affected less than developing ones. Africa is the most vulnerable region for the impact of higher mortality and morbidity, especially among healthcare providers. 16 Sudan's revolution, the terrible economic status, collapsing health system, end-stage arrival of cases due to the centralized isolation centers, difficulty of transportation, and stigmatization of COVID-19 cases all affect the mental well-being of healthcare providers. Although, at present, no data considering the burnout among healthcare providers in Sudan, many published papers confirmed the high prevalence of burnout -among various countries during the pandemic due to diversified factors -leaving no doubt that the crisis is more exacerbated in Sudan. 19,20 4 The term 'Burnout' entails emotional exhaustion, reduced feelings of achievement, and depersonalization 21 . According to studies, the prevalence of burnout among healthcare providers varies from 49.3% to 58% worldwide, and intensivists, emergency department doctors, and nurses are particularly susceptible 22 .
These studies attributed the risk of burnout among healthcare providers to work-related, pandemic-related, and socio-demographic factors. A few examples include age, female gender, insufficient protective equipment, shortages in resources, stigma from the community, concerns about the financial situation, concerns about COVID-19, and workload and job demand 22 .
Burnout prevalence and its consequences on healthcare workers are not well investigated in Sudan. Still, the stigmatization of mental problems in Sudan and the professional stigma of mental illness proposes that healthcare providers repress their mental suffering, navigating to more emotional stress and susceptibility to burnout. 23 Sudan's health system has been facing critical challenges, including a lack of personal protective equipment and other necessary medical equipment. As a result, healthcare workers must deal with COVID-19 without the basic equipment to protect the patients and themselves from the infection. Consequently, this puts tremendous pressure on the doctors, largely due to the poor infection control policies and frustration over being unable to deliver the best possible patient care. 24 The extent of burnout, its distribution between workers in different Isolation centers, and its predictors and protective factors are essential for decision-makers. In our study, we will measure the prevalence of burnout among healthcare providers exposed to COVID-19 patients, so we can contribute with data helping decision-makers fight the battle of the COVID-19 pandemic and the hidden pandemic -burnout -.

Study design and settings
This facility-based cross-sectional study was conducted between 20 th February 2022 and 10 th April 2020 during the last wave of COVID-19. There are ten isolation centers in Khartoum state distributed between the Sudanese Metropolis. These centers are Ibrahim Malik Teaching Hospital, Haj El-Mardi Hospital, Al-Shaab Teaching Hospital, Omdurman, Alnaw Hospital, Ahmed Gasim Teaching Hospital, Bahri Teaching Hospital, Jabra Hospital for emergency and injuries, Omdurman, and Khartoum Teaching Hospital.
We selected the largest and smallest isolation center from the three parts of the Sudanese metropolis.
During the last wave, Ahmed Gasim Hospital was out of service, and there was one active isolation center in the city of Bahri. Therefore, the centers finally included in this study were Alnaw Hospital and Omdurman hospital from Omdurman, Al-Shaab Teaching Hospital, and Jabra Hospital for emergency and injuries from Khartoum, beside Bahri Teaching Hospital from Bahri.

Participants
The study participants were all doctors and nurses who worked in the selected centers during the study period. No one was excluded. We contacted Collaborators from each facility, and online surveys were supplied to them to disseminate to healthcare practitioners. The total number of the targeted healthcare practitioners was 472, and 306 completed the questionnaire, yielding a response rate of 64.8℅

Data collection and tool
The burnout level of the participants was assessed using an online self-administered questionnaire. The questionnaire was divided into five sections, the first of which dealt with socio-demographic characteristics such as age, gender, residence, marital status, number of household members, presence of older family members in the household, history of comorbidities, and history of mental illness.
The second part was about the professional characteristics (isolation center, job title, years of experience, working in ICU, working hours and extra duties, and experience with COVID-19 infection); the third was related to predictors of burnout (COVID-19 among relatives, colleagues, and the patient himself, fear of infection, satisfaction with protective measures of the hospital, feeling of despair about COVID 19 patients). We also investigated adaptive behaviors among the participants (exercise, spirituality, smoking, professional support, self-care, mental breaks, and procrastination), and this was the fourth part of the questionnaire.
The fifth and final part assessed burnout and was based on the Oldenburg Burnout Inventory (OLBI) questionnaire. 25 It is a 16-item validated tool for the investigation of burnout. Items consist of positively and negatively worded questions related to exhaustion and disengagement that are recorded on a fourpoint Likert scale (from 1 = Strongly Agree to 4 = Strongly Disagree); one point designated the lowest burnout and four designated the highest. Disengagement refers to distancing oneself from the content of one's work, while exhaustion refers to fatigue, loss of energy, feelings of emptiness, and a strong need for rest. [26][27][28] Participants were considered at high risk of burnout if they met the thresholds of 2.1 or more for the exhaustion subscales and 2.25 or more for the disengagement subscales with a cut-off point of 35. 28

Ethical approval
Ethical approval for conducting this research was obtained from the Ministry of Health -Khartoum state / Directorate General of Curative Medicine / No: 44, Sudan.
The participants were asked to give consent that they agree to participate in the study by filling the questionnaire for research purposes in the online form, and all the participants provided informed written 6 consent after providing a clear explanation of the study purpose. Data collection was anonymized, and the confidentiality of the study participants was maintained.

Statistical analysis plan
Data were extracted in an excel sheet, cleaned, and imported into the R software version 4.0.2 and SPSS version 28 (SPSS Inc., Chicago, IL, USA). The normality of distribution was tested using Kolmogorov-Smirnov test. Descriptive statistics were used in mean and Standard deviation for the continuous variables and frequencies with percentages for categorical variables. The Chi-square test and Fisher exact test were used to identify variables associated with burnout. Multiple logistic regression analyses evaluated the variables that showed a statistically significant relationship at the bivariate analysis level. The p-value of ≤ .05 was set as the significance level of the study.

Participants information
A total of 306 healthcare workers, with an overall mean age of 26.7 ± 3.8 years participated in the study.

Burnouts among participants
Responses to the Oldenburg Burnout Inventory (OLBI) are shown in ( Table 2). Burnout prevalence was 45.7% among study participants. A low number of household members (p= 0.017) and being a doctor (p= 0.003) were associated with burnout among participants. Also, marital status was significantly associated with burnout (p = 0.001) ( Table 1). Not surprisingly, fear of infection (p < 0.001) and satisfaction with hospital safety measures ( p = 0.002) were associated with burnout.
The most frequent adaptive behaviors were taking brief mental breaks throughout the day (42.2%) and exercising (37.6%) ( Table 3). Interestingly the following factors were not associated with burnout: average income (p >0.9), working years (p = 0.8), working hours (0.8), extra hours (p = 0.065), previous working experience in COVID-19 centers (p = 0.6) working center ( p = 0.8) and site (p= 0.6) and fear of patient death despite all measure ( p > 0.9) The multivariate logistic regression showed doctors were more likely to have burnout than nurses (OR: 1.982, CI 95% 1.217 -3.228; p = 0.006). Also, engaged healthcare workers were less likely to suffer burnout than unmarried healthcare workers (OR: 0.374, CI 95% 0.143-0.980; P = 0.045) ( Table 4).    pandemic, especially frontline staff. The current study addressed a significant issue and provided a better understanding of the problem in a low-income country. Approximately half of the healthcare workers in the COVID-19 isolation centers in Khartoum that were included in the present study suffered high levels of work-related stress and burnout in terms of emotional exhaustion and a lack of personal accomplishment and engagement. Physical and emotional well-being of health staff is critical to pandemic containment.
However, high burnout rates pose significant threat to the delivery of safe and effective healthcare, and negatively influence healthcare providers, patients, and the healthcare system. The high rates of burnout in this study can be explained by the psychological demands of the profession and the high level of socioeconomic pressure and work-related stress that lead healthcare workers to burnout 33 . The country's weak healthcare system, economic meltdown, security situation, political instability and conflicts during this period have placed more pressure on the healthcare system and professionals [34][35] . Moreover, dealing with a high number of patients with poor infrastructure , lack of suitable accommodation and transportation during the lockdown period, concerns about the lack of treatment supplies and personal protective equipment, and the fear of contracting the disease and infecting their families add to the problem. [36][37] . Nevertheless, COVID-19 has been ongoing for over two years, and the constant strain may exhaust healthcare workers' coping mechanisms.
Most of the socio-demographic and other variables assessed in this study were not statistically associated with burnout, reflecting the wide distribution of the problem among the participants despite such differences. We found that a lower number of household members, unmarried individuals, and physician jobs were the only variables associated with burnout among the participants. However, previous studies revealed inconsistent results on burnout risk factors among healthcare workers, and it is unclear whether that burnout follows a specific socio-demographic pattern among healthcare workers 29,31,35 . However, some of these associations with socio-demographic factors can be explainable. Among different medical professions, there are differences in the working duties, which put doctors at higher risk of violence and abuse. In our setting, doctors are the front-liners who deal with angry patients and their relatives, particularly when counseling them about their COVID-19 diagnosis and condition or when breaking the news that a patient has passed away 24,37 . Furthermore, they are responsible for dealing with critically ill patients with a higher risk of complications and mortality 24 .
Regarding the habits used to lessen burnout symptoms, seeking professional support to cope with moral distress and grief was significantly associated with lower rates of burnout among the participants. The participants have used other habits to alleviate the burnout symptoms, such as exercising, spiritual habits, and taking brief mental breaks throughout the day. However, none showed a significant association with burnout rates in this study. 16 The findings of this study acknowledge a high demand for appropriate support interventions and necessitate the search for more effective strategies to be implemented to reduce the risk of burnout among healthcare workers. Using different approaches to reduce burnout, such as training to improve stresscoping skills, can avoid or recover from emotional exhaustion and disengagement. In addition, managing the workplace and environment, improving systems, providing regular psychosocial support, and recruiting additional workers can help address organizational and workplace defects because hostile Working conditions contribute to stress and job dissatisfaction, resulting in depersonalization, emotional exhaustion, and lack of accomplishment 38,39 .

Strengths and limitations
This is one of the few studies assessing the burnout burden among healthcare workers. The sample size of the participants, considered a low response population, is representative of generalizability to overall COVID-19 isolation centers in Khartoum, Sudan. The findings of this study need to be considered in the context of some limitations; as this is a cross-sectional study, it will be challenging to draw causative relationships. The self-reported nature of the study could raise the possibility of recall bias. Also, the study was done in five sites which might limit results generalization for all healthcare workers in all settings in the country and could compromise representativeness.

Conclusion
Our study has shown that nearly half of the healthcare workers in isolation centers in Khartoum have suffered from burnout during COVID-19. Several socio-demographic factors have contributed to the increased level of burnout, and multiple coping mechanisms have accounted for a lower level of burnout among healthcare workers. The findings of this study address the high demand for appropriate interventions to be implemented to reduce the risk of burnout among frontline healthcare workers.  Although public health measures, such as lockdowns, and social distancing, are crucial to reducing the spread of COVID-19, they increase stress, anxiety, and mental disorders. 10 The World Health Organization has recognized "burnout" as an "occupational phenomenon ."As lockdowns have significantly affected our work-life balance and work environments, much research has ascertained burnout and its contributing factors. 11 COVID-19 has a critical psychological impact on the community. 12 The length of the pandemic periodmore than two years -, the shortage of data about the virus treatment, and the unknown destiny of the pandemic resulted in many studies that showed a significant increase in cases of anxiety, psychological stress, and depressive disorders worldwide, and because the medical staff worked under severe psychological pressure: being highly stressed by losing patients and colleagues, preference of having long shifts to protect their families, having no clear curing strategies, and urgency in instructing interpretation, all incredibly highlight peaking of burnout among healthcare providers. [13][14][15][16] Burnout is a critical issue that generates inefficiency in healthcare organizations. 13 It lowers the quality of healthcare systems and negatively impacts patient prognosis. 17 Burnout affects the psychological wellbeing of the staff leading to medical errors. It makes the health system waste a lot of money and resourcesbecause some workers leave their jobs, compelling the system to recruit new staff and offer a new training program. It impedes the process of psychological support for patients, which is part of the treatment. 17,18 Healthcare providers who are emotionally exhausted -express burnout-cannot support patients psychologically nor make fateful medical decisions.
While the pandemic affects the world, studies show that developed countries are affected less than developing ones. Africa is the most vulnerable region for the impact of higher mortality and morbidity, especially among healthcare providers. 16 Sudan's revolution, the terrible economic status, collapsing health system, end-stage arrival of cases due to the centralized isolation centers, difficulty of transportation, and stigmatization of COVID-19 cases all affect the mental well-being of healthcare providers. Although, at present, no data considering the burnout among healthcare providers in Sudan, many published papers confirmed the high prevalence of burnout -among various countries during the pandemic due to diversified factors -leaving no doubt that the crisis is more exacerbated in Sudan. 19,20 The term 'Burnout' entails emotional exhaustion, reduced feelings of achievement, and depersonalization 21 . According to studies, the prevalence of burnout among healthcare providers varies from 49.3% to 58% worldwide, and intensivists, emergency department doctors, and nurses are particularly susceptible 22 .
These studies attributed the risk of burnout among healthcare providers to work-related, pandemic-related, and socio-demographic factors. A few examples include age, female gender, insufficient protective equipment, shortages in resources, stigma from the community, concerns about the financial situation, concerns about COVID-19, and workload and job demand 22 .
Burnout prevalence and its consequences on healthcare workers are not well investigated in Sudan. Still, the stigmatization of mental problems in Sudan and the professional stigma of mental illness proposes that healthcare providers repress their mental suffering, navigating to more emotional stress and susceptibility to burnout. 23 Sudan's health system has been facing critical challenges, including a lack of personal protective equipment and other necessary medical equipment. As a result, healthcare workers must deal with COVID-19 without the basic equipment to protect the patients and themselves from the infection. Consequently, this puts tremendous pressure on the doctors, largely due to the poor infection control policies and frustration over being unable to deliver the best possible patient care. 24 The extent of burnout, its distribution between workers in different Isolation centers, and its predictors and protective factors are essential for decision-makers. In our study, we will measure the prevalence of burnout among healthcare providers exposed to COVID-19 patients, so we can contribute with data helping decision-makers fight the battle of the COVID-19 pandemic and the hidden pandemic -burnout -.

Study design and settings
This facility-based cross-sectional study was conducted between 20 th February 2022 and 10 th April 2020 during the last wave of COVID-19. There are ten isolation centers in Khartoum state distributed between the Sudanese Metropolis. These centers are Ibrahim Malik Teaching Hospital, Haj El-Mardi Hospital, Al-Shaab Teaching Hospital, Omdurman, Alnaw Hospital, Ahmed Gasim Teaching Hospital, Bahri Teaching Hospital, Jabra Hospital for emergency and injuries, Omdurman, and Khartoum Teaching Hospital.
We selected the largest and smallest isolation center from the three parts of the Sudanese metropolis.
During the last wave, Ahmed Gasim Hospital was out of service, and there was one active isolation center in the city of Bahri. Therefore, the centers finally included in this study were Alnaw Hospital and Omdurman hospital from Omdurman, Al-Shaab Teaching Hospital, and Jabra Hospital for emergency and injuries from Khartoum, beside Bahri Teaching Hospital from Bahri.

Participants
The study participants were all doctors and nurses who worked in the selected centers during the study period. No one was excluded. We contacted Collaborators from each facility, and online surveys were supplied to them to disseminate to healthcare practitioners. The total number of the targeted healthcare practitioners was 472, and 306 completed the questionnaire, yielding a response rate of 64.8℅

Data collection and tool
The burnout level of the participants was assessed using an online self-administered questionnaire. The questionnaire was divided into five sections, the first of which dealt with socio-demographic characteristics such as age, gender, residence, marital status, number of household members, presence of older family members in the household, history of comorbidities, and history of mental illness.
The second part was about the professional characteristics (isolation center, job title, years of experience, working in ICU, working hours and extra duties, and experience with COVID-19 infection); the third was related to predictors of burnout (COVID-19 among relatives, colleagues, and the patient himself, fear of infection, satisfaction with protective measures of the hospital, feeling of despair about COVID 19 patients). We also investigated adaptive behaviors among the participants (exercise, spirituality, smoking, professional support, self-care, mental breaks, and procrastination), and this was the fourth part of the questionnaire.
The fifth and final part assessed burnout and was based on the Oldenburg Burnout Inventory (OLBI) questionnaire. 25 It is a 16-item validated tool for the investigation of burnout. Items consist of positively and negatively worded questions related to exhaustion and disengagement that are recorded on a fourpoint Likert scale (from 1 = Strongly Agree to 4 = Strongly Disagree); one point designated the lowest burnout and four designated the highest. Disengagement refers to distancing oneself from the content of one's work, while exhaustion refers to fatigue, loss of energy, feelings of emptiness, and a strong need for rest. [26][27][28] Participants were considered at high risk of burnout if they met the thresholds of 2.1 or more for the exhaustion subscales and 2.25 or more for the disengagement subscales with a cut-off point of 35. 28

Ethical approval
Ethical approval for conducting this research was obtained from the Ministry of Health -Khartoum state / Directorate General of Curative Medicine / No: 44, Sudan.
The participants were asked to give consent that they agree to participate in the study by filling the questionnaire for research purposes in the online form, and all the participants provided informed written 6 consent after providing a clear explanation of the study purpose. Data collection was anonymized, and the confidentiality of the study participants was maintained.

Statistical analysis plan
Data were extracted in an excel sheet, cleaned, and imported into the R software version 4.0.2 and SPSS version 28 (SPSS Inc., Chicago, IL, USA). The normality of distribution was tested using Kolmogorov-Smirnov test. Descriptive statistics were used in mean and Standard deviation for the continuous variables and frequencies with percentages for categorical variables. The Chi-square test and Fisher exact test were used to identify variables associated with burnout. Multiple logistic regression analyses evaluated the variables that showed a statistically significant relationship at the bivariate analysis level. The p-value of ≤ .05 was set as the significance level of the study.

Participants information
A total of 306 healthcare workers, with an overall mean age of 26.7 ± 3.8 years participated in the study.

Burnouts among participants
Responses to the Oldenburg Burnout Inventory (OLBI) are shown in ( Table 2). Burnout prevalence was 45.7% among study participants. A low number of household members (p= 0.017) and being a doctor (p= 0.003) were associated with burnout among participants. Also, marital status was significantly associated with burnout (p = 0.001) ( Table 1). Not surprisingly, fear of infection (p < 0.001) and satisfaction with hospital safety measures ( p = 0.002) were associated with burnout.
The most frequent adaptive behaviors were taking brief mental breaks throughout the day (42.2%) and exercising (37.6%) ( Table 3). Interestingly the following factors were not associated with burnout: average income (p >0.9), working years (p = 0.8), working hours (0.8), extra hours (p = 0.065), previous working experience in COVID-19 centers (p = 0.6) working center ( p = 0.8) and site (p= 0.6) and fear of patient death despite all measure ( p > 0.9) The multivariate logistic regression showed doctors were more likely to have burnout than nurses (OR: 1.982, CI 95% 1.217 -3.228; p = 0.006). Also, engaged healthcare workers were less likely to suffer burnout than unmarried healthcare workers (OR: 0.374, CI 95% 0.143-0.980; P = 0.045) ( Table 4).    pandemic, especially frontline staff. The current study addressed a significant issue and provided a better understanding of the problem in a low-income country. Approximately half of the healthcare workers in the COVID-19 isolation centers in Khartoum that were included in the present study suffered high levels of work-related stress and burnout in terms of emotional exhaustion and a lack of personal accomplishment and engagement. Physical and emotional well-being of health staff is critical to pandemic containment.
However, high burnout rates pose significant threat to the delivery of safe and effective healthcare, and negatively influence healthcare providers, patients, and the healthcare system.
The prevalence of burnout reported in the current study is In line with previous studies assessing burnout among Sudanese healthcare workers during COVID-19. For instance, 71% of resident physicians in Sudan met the criteria for burnout using the OLBI tool 29 . Another study using the Maslach Burnout Inventory assessment tool revealed that 86.1% of resident physicians in Gezira State's teaching hospitals had burnout syndrome 30 . Further, these findings align with other countries that have reported high rates of burnout among healthcare workers during COVID-19 pandemic [31][32][33][34][35] .
The high rates of burnout in this study can be explained by the psychological demands of the profession and the high level of socioeconomic pressure and work-related stress that lead healthcare workers to burnout 33 . The country's weak healthcare system, economic meltdown, security situation, political instability and conflicts during this period have placed more pressure on the healthcare system and professionals [34][35] . Moreover, dealing with a high number of patients with poor infrastructure , lack of suitable accommodation and transportation during the lockdown period, concerns about the lack of treatment supplies and personal protective equipment, and the fear of contracting the disease and infecting their families add to the problem. [36][37] . Nevertheless, COVID-19 has been ongoing for over two years, and the constant strain may exhaust healthcare workers' coping mechanisms.
Most of the socio-demographic and other variables assessed in this study were not statistically associated with burnout, reflecting the wide distribution of the problem among the participants despite such differences. We found that a lower number of household members, unmarried individuals, and physician jobs were the only variables associated with burnout among the participants. However, previous studies revealed inconsistent results on burnout risk factors among healthcare workers, and it is unclear whether that burnout follows a specific socio-demographic pattern among healthcare workers 29,31,35 . However, some of these associations with socio-demographic factors can be explainable. Among different medical professions, there are differences in the working duties, which put doctors at higher risk of violence and abuse. In our setting, doctors are the front-liners who deal with angry patients and their relatives, particularly when counseling them about their COVID-19 diagnosis and condition or when breaking the news that a patient has passed away 24,37 . Furthermore, they are responsible for dealing with critically ill patients with a higher risk of complications and mortality 24 .
Regarding the habits used to lessen burnout symptoms, seeking professional support to cope with moral distress and grief was significantly associated with lower rates of burnout among the participants. The participants have used other habits to alleviate the burnout symptoms, such as exercising, spiritual habits, and taking brief mental breaks throughout the day. However, none showed a significant association with burnout rates in this study.
necessitate the search for more effective strategies to be implemented to reduce the risk of burnout among healthcare workers. Using different approaches to reduce burnout, such as training to improve stresscoping skills, can avoid or recover from emotional exhaustion and disengagement. In addition, managing the workplace and environment, improving systems, providing regular psychosocial support, and recruiting additional workers can help address organizational and workplace defects because hostile Working conditions contribute to stress and job dissatisfaction, resulting in depersonalization, emotional exhaustion, and lack of accomplishment 38,39 .

Strengths and limitations
This is one of the few studies assessing the burnout burden among healthcare workers. The sample size of the participants, considered a low response population, is representative of generalizability to overall COVID-19 isolation centers in Khartoum, Sudan. The findings of this study need to be considered in the context of some limitations; as this is a cross-sectional study, it will be challenging to draw causative relationships. The self-reported nature of the study could raise the possibility of recall bias. Also, the study was done in five sites which might limit results generalization for all healthcare workers in all settings in the country and could compromise representativeness.

Conclusion
Our study has shown that nearly half of the healthcare workers in isolation centers in Khartoum have suffered from burnout during COVID-19. Several socio-demographic factors have contributed to the increased level of burnout, and multiple coping mechanisms have accounted for a lower level of burnout among healthcare workers. The findings of this study address the high demand for appropriate interventions to be implemented to reduce the risk of burnout among frontline healthcare workers.